Veritas Curat

That happens to be on the JIPMER emblem. Translated, it means "Truth Heals". I did and do believe in the saying and have always been truthful to the patients. I believe that there is no harm in undiluted, unvarnished truth and human mind will accept anything after sometime, even if it is unpleasant, and totally negative.This has a great bearing on the future.


Families must be told the truth to plan their future and the patient must be told the truth to accept it.


Otherwise the patients will do reckless things and suffer. (A cardiac patient with a heart attack, if not told the truth, will carelessly do hard work or climb stairs etc. and collapse.)


I have had 2 patients die in the bathroom. They had massive heart attacks and were admitted under my care. I told them that the protocol declares that they be confined to bed at least for 3 days, not getting up even to go to the bathroom. They will have to use a bedpan. They did not understand the gravity, in spite of being told that they may collapse (like Nehru or Zakir Hussain) in the bathroom. But they felt that a bedpan was undignified, pushed aside the relatives and went to the bathroom and collapsed. When things are explained, people are like this, not willing to believe, as they feel apparently alright. If not warned, I shudder to imagine what they may do.


By God's grace, they were the only 2 who did that.


There was another gentleman, who was a terrific smoker (a chain smoker as they were called). He came to me with an Infarction and was in the ICCU. He continued to smoke, even in ICCU. Firstly, I was dead against smoking in the hospital. ( Even Dr. Sankara Sastry and Dr. Seshagiri Rao - friends of ours- never did it in the hospital.). Remembering my futile struggles with my brother, I felt that mere words achieve nothing. So, I told him that he was having a bad heart attack and if he continues to smoke, I refuse to treat him. I went up for my lunch and the staff came running behind me saying that the gentleman walked out. I ran behind him and caught up with him near the end of the street and asked him what he thought he was doing. He said" I can not keep off smoking and since you said I have to stop it, I am discharging myself and the rest is in HIS hands." I asked him to comeback but he refused to and went away. I was terribly worried about him but God, in His infinite wisdom, was kind. That man lived for another 2 years, used to greet me whenever we met, but never approached me for treatment and SMOKED his life away.

Should I have talked to these guys more patiently, convinced them about the risks and then may be they would have lived longer? That is why, I take time to talk and talk and try to persuade people from that time on wards.


There was a case of Cerebral haemorrhage in another hospital and I was called in for consultation. I saw that the situation was hopeless, called the sons aside and told them that the patient will survive a maximum of 2 days. I asked them to call anybody who wanted to be by the bedside and to check and see the documents, LIC policies etc. to see how the name is spelled, so that they can take a properly spelled death certificate. Otherwise, they will have a lot of trouble in getting the money and transferring property. Gopal who came with me, out of curiosity, for the nocturnal visit was aghast. He asked me " how can you be so direct with such news?" I said that my job is to treat and the power of life is not in my hands. I know the patient will die soon and so the best I can do for the family (my next target) is to prepare them.


Was I right or heartless and uninvolved? What do you think?


A lady, a longstanding diabetic with poor heart function came to me with complete heart block. The entire family works in shops as clerks etc and still there is a gap between both the ends (the ends do not meet). She needed a pacemaker, costing rs 10,000+hospital expenses. They said that they could not raise the money. I sent them to JIPMER. The cardiologist agreed to do it but as the pacemaker was not available, they had to buy it. As she was an old lady, I asked them to consider their finances also. Without treatment, she may survive 2 or 3 years and with treatment may be 5 years. She has to be guarded all the time in either case. They elected to get her treated and raised a loan of rs. 15000. Meanwhile, she was admitted under our care. We had gone out for a social visit one evening. She had a cardiac arrest. Our efficient staff of Kotaiah and Mumtaz revived her and by the time we got back, she was alright. She underwent pacemaker implantation, came back and was convalescing. She had a sudden cardiac arrest again 2 months post-op and died before she could be revived, as she was at home. The family sold whatever they had, repaid the debt and left town. All the male members became daily laborers and females were doing whatever they can at home. The entire family was ruined with nothing left.
Now, here is the tricky question. Was I right or wrong in asking them not to go ahead with pacemaker implantation? I ask for your opinions.

My First Mistake (and so soon)

Gowri says that I am a fantastic listener (Opigga Suthi veyinchukuntavu) and Sarada says that I am a patient persuader/negotiator. I cultivated both these things after committing a grand, cardinal mistake on my very first duty day. Thank GOD, it was not fatal. I made myself a promise to listen patiently, elicit history diligently and explain properly, patiently in spite of interruptions from the patient.
This was how it went.
I was on duty as a house surgeon in Medicine. Our day (on OP days) starts at 7.00 am with ward rounds, after which we have to go to OPD. We have to be in our seats by 8.00 am for our boss will peep in at 8.02 and note absentees. Then OP will go on till 12.00 and/or past that till the last patient leaves. (usually by 2.00 pm). Meanwhile the house surgeon on duty will go to the hostel for lunch at 12.30 and be back by 1.30 pm. All cases admitted on that day in OPD belong to that unit and all emergencies that come to Casualty (Emergency dept) as well as all the case that are treated there after OP hours belong to that unit. The duty of the house surgeon is to be on call and attend casualty, examine the patient and prescribe what is needed and send him away or admit him depending upon the need. Seniors are always available on call for advice and will even come down if called. (Remember about me calling my registrar 4 times in the night and getting banged for making silly calls.)
After the patient (non emergency) is admitted or after the preliminary treatment of the emegency case is done, comes the drudgery.
A detailed history is to be taken and a case sheet needs to be written with following headings--Presenting complaint, history of the Presenting complaint, Past history of such complaints or past episodes, past history of any other illness, Any drug treatment given previously and current medication, personal history like bowel bladder and food habits, places visited recently, family history of illnesses etc. Then the examination findings are to be recorded, a prelimianry diagnosis is made, routine lab tests (blood, urine, sputum if indicated) are to be done by the house surgeon and he should be ready with all data for rounds by chief and assistant at 7.00pm. Imagine all this to be done for 7 or 8 cases between 2.00 pm and 5.00 pm because evening OP will be there between 5.00 pm and 7.00 pm.
This will be interspersed with calls from casualty.
I forgot the underlined part in my nervousness, cockiness (I know all that is there to know--I am the best outgoing student in Medicine, am I not?) and pressure of treating a patient on my own for the very first time. (of course I can call on my senior, but if I keep calling for everything, what am I there for?)
That was the mindset with which I tackled my first emergency.
He was a 50 year old gentleman complaining of breathlessness. I examined him straightaway and found that he had a diseased Mitral valve and was in heart failure. The heart was dilated and there was some water in the lungs. So confidently, I said " sister! 1 ampoule of Digoxin (1mg) and 2 ampoules of Lasix (40 mg) IV please". These were the loading doses and more will be given later if necessary.
It was  given and then I sat down to write the case sheet.
His brother who came in just then brought some presciptions which were given to the patient by a doctor in their place. He was on Digoxin 0.25 mg daily (maintenance dose) and lasix 1 tab. per day.
That meant he was already loaded and was now on maintenance. I had gone and added 4 times the maintenace dose in one shot and I had not given Potassium Chloride yet. Low Potassium will increase Digoxin toxicity.
Did I kill him?- was my thought. I got panicky and went and examined the patient again. To my consternation, his heart was going fast and irregularly ( Atrial Fibrillation).
I was nearly in tears and called my registrar, who was 3 years my senior.
He came in, saw the patient and confirmed that it indeed was Mitral Valve disease, enlarged heart, Congestive heart failure and Atrial fibrillation.
I told him about my mistake-no, blunder-of giving 1mg. Digoxin IV. He just said h'm and called the patient's wife and asked her about the medication being taken by the patient.


She said that he had stopped taking drugs for the last week as he was vexed with swallowing tablets.

All the Digoxin had gone out of his body and he did need the loading dose and more digoxin after 6 hours. We gave him 15 ml. of Potassium chloride and put him in ICU. By god's grace, what I did was correct but I escaped a catastrophe by a whisker. If he was a good patient and was regular, then we would have been hard put to get him of Digoxin poisoning.

My registrar said "see! now you know the importance of diligent history taking. If you elicited the drug history, you would not have rushed in with Digoxin. And--if you talked to the wife as part of current medication history, you would not have yanked me from my house at 7.30 pm on an emergency call and would have done just what you did at 7.00 pm because you were right. Let all the tension you underwent be a lesson not to be forgotten and be a good doctor. An intelligent doctor is not a great doctor but, a caring, diligent doctor is a great doctor." He then ordered coffee for me, the CMO and for himself and after the coffe he went home. Procedures are devised with a view to run things like clockwork. We ignore them or use shortcuts to our detriment.

That is a lesson that has stayed with me till today. The persuasion part will come later.
This is about the listening part.